Step-up therapy involves starting treatment with the less potent agents & moving up for treatment response

If patient does not respond to an H2RA within 2 weeks, switch to proton pump inhibitor

If patient does not respond to this regimen but some improvement in symptoms are seen, dose of proton pump inhibitor may be increased

Consider other therapeutic options in PPI-resistant gastroesophageal reflux disease include switching to a different proton pump inhibitor, changing medication time, or adding a prokinetic agent or an H2RA at night

If patient still does not respond to above regimens, patient’s symptoms are likely not secondary to reflux & warrant diagnostic testing & referral to pediatric gastroenterologist

Step-down therapy makes use initially of a potent acid suppressant, then decreasing dose or switching to less-potent agents

Proton pump inhibitor dose should be tapered for at least 4 weeks, then weaning from proton pump inhibitors using H2RA to control rebound may be considered

This is followed by stepping down further to on-demand use of antacids if patient was asymptomatic while taking an H2RA

Dr Michael Lim, a senior consultant at the Paediatric Pulmonary and Sleep Division, National University Hospital, Singapore, speaks to Roshini Claire Anthony on the rare disease that is cystic fibrosis.

Susceptibility‐guided therapy is as effective as empiric modified bismuth quadruple therapy for the first-line treatment of Helicobacter pylori infection, with both yielding excellent eradication rates, as shown in a recent trial.

The risk factors and outcomes associated with an increased risk of permanent pacing include atrial fibrillation (AF) ablation, multivalve surgery and New York Heart Association (NYHA) functional class III/IV, a recent study has found.